Treatment

Endoscopic Assessment

Two critical questions must be answered about every newly diagnosed esophageal stricture: (1) Is the stricture benign or malignant, and (2) if benign, can it be dilated? The relative technologic explosion in the variety of available flexible fiberoptic esophagogastroscopes and instrumentation possible through them has resulted in this instrument becoming the most common means of assessing the esophageal lumen and

stenoses visually. Rigid esophagoscopy still has its place in the esophageal surgeon's armamentarium because it provides larger and more meaningful biopsy specimens with which to assess changes of reflux esophagitis, but its use is now restricted to the patient in whom passage of the flexible instrument is not possible, and general anesthesia is required. Endoscopic assessment of any esophageal stricture requires adequate patient sedation and anesthesia, because this is an uncomfortable procedure that mandates the surgeon's complete concentration on the endoscopic field, not on a moving, struggling patient.

Adequate esophageal biopsies and brushings for cytologic evaluation of the stricture should be performed in the initial endoscopic assessment of the stricture, as the combination of esophageal biopsy and brushings establishes the diagnosis of carcinoma in more than 95% of patients with a malignant stricture. If there is no evidence of neoplasm with either of these studies, there is a high likelihood that the esophageal stenosis is benign. After the biopsy, dilation of the stenosis is performed. The standard adult flexible esophagoscope is the size of a No. 32 French esophageal dilator, and a mild stricture can be dilated directly by advancing the instrument through it. After this, passage of progressively larger Hurst-Maloney tapered dilators is performed beginning with a No. 32 French size and advancing to at least a No. 46 French size, but preferably larger depending on the resistance encountered. Virtually every reflux stricture that can be dilated by mouth to a No. 40 French size bougie can be dilated later intraoperatively to the 54 to 60 French range (see later section, "Surgical Treatment"). Patients with intractable esophagitis or dysphagia who are likely candidates for antireflux surgery, therefore, need not undergo dilation much beyond a No. 40 French size preoperatively unless relatively little resistance is encountered to passage of the bougies. Those for whom periodic dilations and

Figure 13-5 Equipment needed for the initial evaluation of an esophageal reflux stricture: a ruler for precise localization of the pathology (in centimeters from the incisor teeth); a biopsy forceps (and cytology brush, not shown) to exclude carcinoma with biopsies and brushings of the stricture; and gum-tipped Jackson dilators, manipulated gently through the stricture, to assess the length and pliability of the obstruction. The No. 26 French dilator is the largest size that passes through the standard 45-cm rigid esophagoscope.

Maloney Dilators Bougie Sizes
Figure 13-7 Tapered Maloney esophageal dilators and the special-order Pilling 45-cm esophagoscope, which will accommodate a No. 50 French dilator, used to dilate dense, severe reflux strictures under direct vision.
Pilling Esophagoscope

Figure 13-8 Esophagogram showing A-) eccentric complex reflux stricture (smallarrow) at esophagogastric junction proximal to a large sliding hiatal hernia. Because of the diverticulum-like configuration of the lumen in the region of the stricture, blind passage of a Maloney bougie was thought to be unsafe. B, Several sizes of the polyvinyl Savary-Gilliard dilators with a guidewire passed through the upper dilator. C, Radiographic confirmation of the proper course of the endoscopically placed Savary guidewire (arrows) through the esophageal stenosis and into the stomach (same patient as shown in A). Progressively larger Savary dilators up to a No. 54 French were passed over the wire and through the stricture. Blind passage of Maloney dilators on an outpatient basis was then achieved without difficulty. (From Orringer, M.B.: Short esophagus and reflux stricture. In Sabiston, D.C., Jr., and Spencer, F.C. [eds.J: Surgery of the Chest, 6th ed. Philadelphia, W.B. Saunders, 1995, p. 1066, with permission.)

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